Milton Charitable Foundation

ForThe Visually Handicapped

A state cadre non-profit charitable foundation

Ashok Nagar 5th Line Main Road, Berhampur,

Ganjam, Odisha-760004

Phone: 0680-2280433/9338689961.

E-mail: , WEBsite:

Application for Equipment Assistance

I. Personal Information:

  1. Name of the applicant: ______
  2. Date of Birth: ______
  3. Marital Status: ______
  4. Name of current institution : ______
  5. Class in which you are studying : ______
  6. Do you have any study device viz, computer/ CD player/ mp3 recorder: Yes/No
  7. How did you here about this scheme: ______
  8. Did you have ever got any assistance/support from this foundation (Briefly Mentioned) : ______
  9. Did you have ever got any equipment support from any institution (Give Details):

______

  1. Why do you need equipment support please explain: ______

II. Contact Information:

  1. Parent Name: ______
  2. Parents occupation: ______
  3. Number of family members: ______
  4. Permanent Address (Pin number must) : ______
  5. Address for Communication (Pin number must) : ______
  6. Your Phone number (must): ______
  7. email address (if any): ______

IV. CHECK LIST:

I have enclosed the following documents:
a) Attested copy of all educational certificates with Mark sheet.
b) Attested copy of Parents Income certificate.

c) Attested copy of Blindness Certificate

d) One recent passport size photograph.

e) Original Study Continuing Certificate.

f) Any other additional Information:

DECLARATION:

I hereby declare that, neither I have got any equipment support for study purpose nor I have been selected for availing this kind of support from any institution. I have read all the instructions carefully and filled up the application correctly, the above information given by me is true to the best of my knowledge and I agree to abide by the rules and regulations of Milton Charitable Foundation for the Visually Handicapped. If the information given above along with the documents will be found false then my selection for this scheme shall be liable to be cancelled.

If the organization will get the information about possessing any study equipment as mentioned above previously and I will be eligible to get this support currently then the organization may refund the equipment from me in the future. Neither I will transfer nor sell the equipment to the third party in the future, if so I will be debarred of availing any facility from the organization.

Place: ______

Date: ______Signature of the candidate

______

Signature of the parent

______

Signature of the Head of the institution with seal